Universal health coverage and social determinants of health.

As the global health community embraces universal health coverage, a lesson from the 1978 Declaration of Alma Ata is worth remembering. The Declaration was a landmark in global public health and was the conclusion of one of the most important international conferences on primary health care. But in Alma Ata, it was recognised that there was more to improving population health than primary health care. The Declaration called for resources to be devoted to peaceful aims, “and in particular to the acceleration of social and economic development of which primary health care, as an essential part, should be allotted its proper share”. However, the part of Alma Ata about social determinants—acceleration of social and economic development—was largely forgotten and left out of the international agenda. Improvement of access to primary care is a worthy and necessary goal but, by itself, will not revolutionise global health, nor reduce large health inequalities. For example, the UK has an equitable health service that is free at the point of use, but widening health inequities. Action also needs to be taken to address the social determinants of health: the conditions in which people are born, grow, live, work, and age, and the inequities in power, money, and resources that give rise to them. There is a danger of going down the same route again with universal health coverage to the apparent detriment of action on social determinants of health. WHO is clear in its defi nition of universal health coverage: all people obtain the health services they need without suff ering fi nancial hardship to pay for them, a well run health system, a system for fi nancing, access to essential medicines and technologies, and well trained health workers. Universal health coverage is a noble goal, but so too is action on social determinants to achieve health equity. The latter should not be forgotten. Both WHO and the UN declaration on universal health coverage note the importance of locating universal health coverage in the context of action on social determinants of health. However, these two things are not interchangeable. Health care is just one determinant of population health. Other inputs to health, such as social protection, good employment, and early years care, should not be forgotten, but they have been. For example, a joint WHO and World Bank report on universal health coverage does not mention social determinants of health amid its commendable concern that people should not be impoverished by the cost of health care. This situation can be dealt with in two ways: work to include social determinants of health within uni versal health coverage, or recognise that these are complementary activities, both of which are important for population health. We should do both. For example, economic austerity is bad for health, not only because of its eff ects on funding of health services, but because of adverse eff ects on housing, income, and employment. Universal health coverage is unlikely to direct much attention to action by ministers of fi nance to reduce childhood poverty, provision of pre-school education, or community empowerment to negotiate loans to improve housing quality. However, much can be done to improve social determinants of health from within the health sector, including changes in clinical practice, partnership working, advocacy, education and training, and employment conditions of health-sector workers. One important way to ensure that social determinants of health remain central to the concerns of those pur suing universal health coverage is to include social determinants in a monitoring framework, which is easy to implement and has two components. First, monitoring of all health and health-care measurements by socioeconomic position, sex, geographical distri bu tion, or other relevant markers of health equity, such as education. If health and